Printable Refusal Of Medical Treatment Form Involved the possible alternatives to the treatment and the consequences of my refusal to my health and well being and I understand all of this information Dr has given me the opportunity to ask questions and the doctor has answered my questions about the proposed treatment I understand that my refusal is against the medical advice
Brief Narrative Description of the Incident I hereby acknowledge my refusal of medical treatment and or observation offered to me at the expense of Santa Clara University for the work related injury I incurred on By signing this form I realize that I do not necessarily affect my later eligibility for Workers Compensation Employee Refusal of Medical Treatment Form I have been advised by my supervisor safety specialist that I may seek medical treatment for the injury that may have occurred on the job per the below listed information
Printable Refusal Of Medical Treatment Form
Printable Refusal Of Medical Treatment Form
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FORM 5 1 Refusal to Permit Medical Treatment My doctor physician name has advised the following medical treatment My doctor has informed me of the following The nature and advisability of this medical treatment The risks and complications of this medical treatment The expected benefits of this medical treatment Opportunity to seek necessary medical treatment and or observation At a later time I understand that I may request a medical evaluation for the above described injury By signing this form I acknowledge any future claims regarding this incident will require a medical evaluation through an approved ECU Worker s Compensation medical
Informed Refusal Process Conduct the informed refusal dialogue with the same degree of specificity and care used in the informed consent discussion If a patient indicates an unwillingness to undertake treatment especially if failure to do so may result in death attempt to determine the basis of the patient s decision The patient meets all of the following Is a patient over the age of 18 yrs Exhibits no evidence of Altered level of consciousness Alcohol or drug ingestion that would impair judgment Understands the nature of the medical condition as well as the risks and consequences of refusing care Acknowledgement of Information Initial on line
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REFUSAL TO CONSENT TO TREATMENT MEDICATION OR TESTING Individuals are legally entitled to exercise their freedom of choice by choosing not to undergo a recommended course of treatment medication or testing Having considered all of my options and understanding the risks of declining the treatment medication or testing I have decided not Treatment at hospital name However I refuse further medical examination and treatment I have been informed of the risks and consequences potentially involved in this refusal the possible benefits of continuing medical treatment at this hospital and any alternatives to my decision to refuse further examination and treatment
I patient name give permission for practice name to give me medical treatment I allow practice name to file for insurance benefits to pay for the care I receive practice name will have to send my medical record information to my insurance company I must pay my share of the costs I must pay for the cost of these services if my Alternate treatment recommendations I am provided with this refusal form and information so I may understand the recommended treatment and the consequences of refusing treatment I have had an opportunity to discuss and ask questions concerning the recommendations and alternative treatment recommendations
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Involved the possible alternatives to the treatment and the consequences of my refusal to my health and well being and I understand all of this information Dr has given me the opportunity to ask questions and the doctor has answered my questions about the proposed treatment I understand that my refusal is against the medical advice
https://www.scu.edu/media/offices/human-resources/documents/benefits/forms/Refusal_of_Medical_Treatment_or_Observation.pdf
Brief Narrative Description of the Incident I hereby acknowledge my refusal of medical treatment and or observation offered to me at the expense of Santa Clara University for the work related injury I incurred on By signing this form I realize that I do not necessarily affect my later eligibility for Workers Compensation
Printable Refusal Of Medical Treatment Form
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Printable Refusal Of Medical Treatment Form
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Printable Refusal Of Medical Treatment Form - FORM 5 1 Refusal to Permit Medical Treatment My doctor physician name has advised the following medical treatment My doctor has informed me of the following The nature and advisability of this medical treatment The risks and complications of this medical treatment The expected benefits of this medical treatment
